Cancer, Coverage, and COVID-19

Amid the medical news dominated by coronavirus disease 2019 (COVID-19), the JAMA Network has published a set of articles that boost our understanding of the critical role of insurance coverage in cancer treatment. A recent article in JAMA Pediatrics quantified the extent to which Medicaid expansion leads to increased insurance coverage for children with cancer.¹ Recent research comparing Medicaid expansion states with nonexpansion states has demonstrated that insurance coverage improves survival for non–small cell lung cancer, in part because of earlier diagnosis.^2,3 Yet, important differences in cancer survival may also exist by insurance status, with Medicaid coverage being the least advantageous for cancer outcomes compared with Medicare and private insurance.^4,5

We also know that disparities in early-stage detection of breast cancer are associated with insurance status and especially with lack of insurance.⁶ Furthermore, we have learned that children of color have worse cancer outcomes, with disparities more pronounced among cancers more amenable to treatment, likely owing to access to care—which is itself driven by insurance status and household financial resources.⁷

In addition, economists have long taught their students about the job lock that results from an employer-based system in which individuals become “locked” in jobs to maintain their insurance. New estimates published this spring in JAMA Oncology indicate that 1 in 3 adult cancer survivors report that they or their spouse/partner experienced job lock.⁸ Those with an income between 138% and 400% of the federal poverty level were at increased risk because they were low income yet did not qualify for Medicaid even if their state of residence had expanded Medicaid coverage.

At any other time, this collection of findings might have increased calls for insurance coverage options; however, they have arrived at a moment when attention is focused on the millions who have lost their jobs, with those least able to maintain coverage being the most affected.^9,10 The Kaiser Family Foundation estimates that more than 20 million people losing job-based coverage will be eligible for coverage through Medicaid or Marketplace plans, but 6 million are not eligible and are at risk of becoming uninsured. Therefore, people who do have a job may be more locked in it than ever during a recession.

On top of this, there is a growing understanding that COVID-19 will bring with it excess deaths owing to lower cancer screening rates, even in the absence of the economic upheavals that are disrupting insurance coverage. Ned Sharpless, director of the National Cancer Institute, has estimated that there will be an additional 10 000 excess deaths from breast and colorectal cancers alone because of lower screening rates.¹¹ He likened this to a public health crisis within a public health crisis. Given what we now understand with more nuance than ever, rising uninsurance is yet another layer to these crises faced by current and future patients with cancer.

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